**Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you!

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1 Checking Your Insurance Benefits IMPORTANT Please check your insurance coverage prior to any Nutrition or Diabetes Education appointment. You will be responsible for any services that are not covered. Call the number on the back of your insurance card and give them the following information: 1. You are being seen at Hunterdon Medical Center. Our NPI # is Our TAX ID # is (Your Insurance will not locate our facility by name or educator) 2. You will be billed as *OUTPATIENT SERVICES* NOT a doctor s office. 3. The procedure codes are: o Diabetes Education with a Nurse G0108 (Diabetes Education) o Medical Nutrition Therapy with a Registered Dietitian: (Nutrition Diagnosis ONLY: Check the 2 procedure codes below.) (Initial Visit) (Follow Up Visit) If you are scheduled with both a nurse and a dietitian, please check all 3 codes. 4. Be sure to ask for the representative s first name and last initial and a reference number for the call. Document the date of the call for your files. 5. Additional questions to ask your insurance company: o Any limitations on visits and how many visits per calendar year are allowed? If visits are limited, are there different limits for the Diabetes Nurse and the Registered Dietitian? o Are Referrals or Pre-Certification required? If a referral is needed, please call your doctors office and bring it the day of your appointment. If you need a Pre-Certification please contact us. o What is your responsibility: co-pay, co-insurance, or deductible? o Be sure to ask for the representative s first name and last initial, a reference number for the call and document the date of the call. If your insurance informs you that our services are NOT a covered benefit please call our center so that we may discuss other options or have your insurance company representative contact our office at **Medicare and Medicaid have other Billing Codes and different eligibility. Please contact our office for more information. Thank you! 1 of 6

2 To Our Bariatric Surgery Patients: Thank you for choosing Hunterdon Medical Center for your nutrition counseling. Your registered dietitian will be instructing you on nutrition requirements and weight management techniques based on the type of gastric bypass surgery that you have chosen. If you are preparing for bariatric surgery: Please be aware that your surgeon may have specific guidelines that he/she wants you to follow regarding your diet before and after surgery. You should bring these instructions to the registered dietitian on your first visit. If you are not able to obtain these guidelines, the dietitian will be using instructions from the Academy of Nutrition and Dietetics and the bariatric program at Hunterdon Medical Center. The instructions may be similar, but it is important that you are following the requirements set by your surgeon. If you have already had your bariatric surgery, you should bring a copy of the dietary guidelines that you are currently following as advised by your surgeon. Please fill out the enclosed nutrition assessment forms and bring them to your first visit. Also, please bring the person who prepares the meals in your family to your sessions if possible. We are looking forward to working with you to help you successfully and safely get the most from your bariatric surgery. Thank You, Community Nutrition, Hunterdon Medical Center of 6

3 Center for Nutrition and Diabetes Management Weight Loss Surgery Nutrition Assessment Name: Date: Age: Type of Surgery: Gastric Bypass Adjustable Gastric Banding Vertical Sleeve Gastrectomy Pending date of surgery: Number of visits needed: Height: Current Weight: Desired Goal Weight: _ Usual Body Weight: Highest Weight: Childhood Weight: (Circle) Underweight Average Overweight History of Anorexia/ Bulimia yes no Do you have a tendency to: binge eat eat when stressed eat when upset/sad eat night graze Brief history of weight loss attempts (Include name of programs, weight lost, regained?) Medical History (please circle all that apply) Sleep Apnea Diabetes Pre Diabetes High Cholesterol High Blood Pressure Arthritis Heart Disease PCOS Other Please list Food Allergies and/or Drug Allergies: Please list nutritionally pertinent medications and supplements: Are you presently exercising? Reasons for not exercising: If Yes, what is your regimen _ 3 of 6

4 Learning Style Have you had previous nutrition education? No Yes If yes, where and how long ago: The most important things I want to learn today are: Intake History Do you drink alcohol? No Yes If so, how much? Do you smoke? No Yes If so, how much? Do you have any religious or cultural observations that affect how you eat? If yes, please explain: Who prepares your meals? How your food is usually prepared? Fried Baked Grilled Broiled Other How many times a week do you eat away from home? Fast Food Restaurant Take out Other Do you: Skip meals Nibble between meals Eat rapidly Have food cravings Use convenience foods Eat unplanned meals Other: Based on one day: How much milk or yogurt do you consume? How many vegetables? How many fruits? How much water do you drink in one day? What are your main beverages? Please list any trigger foods that may make you overindulge: 4 of 6

5 Please record a usual day. What kind of food? How much food? BREAKFAST Time MORNING SNACK Time LUNCH Time AFTERNOON SNACK Time DINNER Time EVENING SNACK Time, R.D. Date: Page 3 of 3 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Office Use Only Please Educational Materials Provided: 5 of 6

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